Chest
Volume 108, Issue 6, December 1995, Pages 1683-1689
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Reviews
Thrombolytic Therapy of Left-Sided Prosthetic Valve Thrombosis

https://doi.org/10.1378/chest.108.6.1683Get rights and content

Thrombosis of left-sided prosthetic valves is an uncommon yet potentially serious complication. Thrombolytic therapy has been proposed as an alternative to surgical methods in treating this condition. We sought to determine from a review of the literature what outcomes may be expected subsequent to thrombolytic administration and what groups may be at risk or benefit from this approach. We searched for studies including two or more patients treated with thrombolytic agents. Ten studies were reviewed. We describe and include two patients with valve thrombosis treated at our institution. A total of 182 episodes of prosthetic valve thrombosis in 162 patients were examined. Clinical success was achieved in 72.0% of cases and there was a mortality risk of 9.9%. Clinical success from thrombolysis was significantly related to the degree of heart failure at presentation and aortic valve position. Clinical success was not related to the duration of symptoms, time from valve replacement to obstruction, or valve type. Rethrombosis of successfully treated valve occurred subsequently in 19.5% of cases. Repeated thrombolytic administration in these patients was associated with similar rates of success as those treated for their initial episode of prosthetic valve thrombosis. Candidates for thrombolytic therapy include patients with obstructive valve thrombosis with or without congestive heart failure who are hemodynamically stable. Duration of time since valve replacement or symptom onset does not limit successful outcome. Close observation and aggressive maintenance of anticoagulation after therapy is suggested.

Section snippets

Patients

Both patients underwent cinefluoroscopy to demonstrate valvular leaflet obstruction. Measurements of excursion angles were performed as previously recommended.6 Repeated cinefluoroscopy was performed within 24 h of therapy. Visualization of thrombus was confirmed by transesophageal echocardiography (TEE) in each patient. Confirmation of improved valve function was performed by Doppler echocardiography within 24 h of therapy. Urokinase was administered intravenously with a bolus dose of 4,400

CASE 1

A 76-year-old woman underwent aortic valve replacement with a 21-mm valve (St. Jude Medical Valve) for severe postrheumatic aortic stenosis. Owing to the patient's general debility, the postoperative course was prolonged and she required transfer to a convalescent center for rehabilitation. Six weeks after surgery, she developed acute right calf pain and lower leg numbness. A later arterial scan revealed an occluded right superficial femoral artery and suggested a previous embolic event. The

Discussion

The administration of thrombolytic agents has been recommended as initial therapy for prosthetic valves with thrombosis in the tricuspid position. However, caution has been advised in regards to left-sided valve thrombosis because of the concern of cerebral and peripheral thromboembolism. Because of the low incidence of PVT, random comparative evaluation of medical and surgical modalities of treatment has not been performed. Several clinical reports have suggested clinical efficacy of

Acknowledgment

We gratefully acknowledge the secretarial assistance of Susan Freppert in the preparation of this manuscript.

References (21)

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